Physical Medicine and

Rehabilitation

Introduction
Lesson I

Prof. A.S. Nica

S.L. Brindusa Mitoiu
S.L. Consuela Brailescu
 Definition of Medical Rehabilitation

• Medical "Recovery = Rehabilitation" represents a

complex form of medical-social assistance, but at
the same time unitary in conception, which is
continuous and has the final aim of reintegrating
people with disabilities into society, its means of
action aiming to obtain optimal values of all three
vital parameters of any individual:
• morphologic and functional capacity,
• mental state,
• socio-professional condition.
Synonyms = re-education, re-adaptation
 Definition of Medical Rehabilitation
• USA - Physical Medicine and Rehabilitation pioneer in
specialty (after the II -nd World War)
• Europe - Physical Medicine associates also: methods of
physical therapy and balneology /thermal therapy
(tradition of Balneology, Medical Hydrology and Thermal),
in Germany, France, Italy, Spain and Sports Medicine
• Romania - the inter-war period Balneology, introduced by
Cluj Medical School -1928 was initially developed in
Transylvania on the German model with elements of
French, English, Swedish, American, Russian Recovery in
Physical Medicine
• Romanian Balneoclimatology has an important spa
potential (30% of Europe's mineral water sources)
 Definition / Name

• 2007- European Union of Specialist Physicians

(EMU):
– "Use of all means to reduce the impact of disabling
conditions ... and offer the possibility of optimal social
integration of persons with disabilities"
– "a complex activity, medical, educational, socio-
professional, through which is aimed to restore the lost
functional capacity of an individual, congenital or as a
result of diseases or traumas, as well as the
development of compensatory mechanisms to ensure
the possibility of work or self-service, an active and
independent economic and / or social life ”
 Definition / Name
• 2012 WHO:
– ‘’a set of measures to assist individuals with
disabilities to achieve and maintain optimal
functioning in interaction with their
environment’’
– ’’ aims to improve the function by diagnosing and
treating the disorders, reducing the deterioration
and prevention and treating the complications ".
 Definition / Name
• 2013 Ministry of Health of Romania - The specialty
of Recovery / Rehabilitation, Physical Medicine
and Balneology is a ,,clinic and therapeutic
specialty focused on the study of all types of
disability (present or potential) and specific
application in prophylaxis and therapy”
• Independent clinical specialty, responsible for the
prevention, diagnosis, treatment and management
of the rehabilitation for people with disabling
conditions and comorbidities at all ages, in order to
promote the physical, cognitive capacities and
performances, as well as to improve the quality of
life.
Medical Rehabilitation Definition
 IDH
According to the classification of IDH (International Classification of
Impairments Disabilities and Handicaps) 2001:
• Infirmity is "any loss or abnormality of an anatomical, physiological
or psychological structure or function".
• Disability is the restriction or loss of the ability to perform an
activity considered normal for an individual”. If the infirmity
expresses a local consequence at the level of the injured organ, the
incapacity is the result of the infirmity reflected in the individual's
disability to perform some activities (locomotion, dexterity, self-care,
communication, etc.).
• The handicap is "the difficulty of an individual to achieve normal
relations with the living environment in accordance with his age, sex,
social and cultural conditions“= participation The disability is
determined by a difficulty, respectively by the state of incapacity. Not
every infirmity causes disability.
• Each element of the triad: Infirmity, Disability, Handicap may be
influenced by rehabilitation programs
International Classification of
Functions (CFI / ICF)
 The ICF Objectives
 Ensures understanding and analysis of health status,
associated states and consequences, taking into account
environmental factors;
• Establishes a common alphabet for describing health
status, associated states, improving communication
between different users (health services staff, researchers,
policy makers and population, including people with
disabilities);
• Provides the appropriate framework for statistics and
reporting, with the possibility of comparing health data
and health care services between different states;
• Ensures a unitary and systematic coding scheme for health
information systems and databases.
 Rehabilitation Indications
•The healthy individual: primary prophylaxis;
• Different types of pathologies focus on somatic
dysfunctions and disability:
–neurological and neurosurgical,
–musculoskeletal- rheumatologic and orthopedic,
post-traumatic
–respiratory and cardiovascular,
–hematologic, oncologic, nutritional,
–gynecologic-obstetric and kidney-urinary,
–pediatric, geriatric disabilities.
 Where does it take place?
• Hospital: intensive care, neurology, orthopedics,
surgery, neurosurgery, cardiology, cardiovascular
surgery, plastic and repair surgery, pulmonology,
gastroenterology, pediatrics, oncology departments
etc.
• Medical rehabilitation centers;
• Departments of chronic patients;
• Department of geriatrics;
• At the patients' home.
Who is in charge?
Rehabilitation
doctor

Psychologist Physiotherapist

Medical
assistant Patient Occupational
therapist

Speech
Orthotist
therapist

Social
assistant
 Physical Medicine and Medical
Rehabilitation

Therapeutic specialty with two components:

• Physical Medicine - the functional diagnosis can
be established using specific evaluation
methods
• Medical Rehabilitation – rehabilitation strategy
for adapted programs of functional somatic
recovery;
Physiotherapy – another paramedical profession
focused on the application of physical modalities
in rehabilitation medicine
 Therapeutic Objectives in Medical
Rehabilitation

• Pain relief by pharmacologic and non-

pharmacologic conservative methods;
• Improvement of the functional somatic
status: mobility, stability, ability, physiologic
motor activities, different types of
movement, gait;
• Improvement of the quality of life.
 Quality of Life

• WHO defined quality of life as ”an individual's

perception of their position in life in the context of
the culture and value systems in which they live and
in relation to their goals, expectations, standards
and concerns. It is a broad ranging concept affected
in a complex way by the person's physical health,
psychological state, personal beliefs, social
relationships and their relationship to features of
their environment”.
 Criteria and Indicators of Improving
the Quality of Life
Nr Criteria Indicators
1 good physical condition pain, fatigue and endurance, strength, sleep,
nutrition
2 decrease of functional achievement of daily activities (ADL),
dependency mobility, balance, complex physical activities
3 cognitive ability the ability to concentrate, integrate,
compatible with social memorize, reflect and logic
insertion
4 psycho-behavioral awareness and acceptance of disability,
stability ability to anticipate, express and manage
emotions, motivation
5 social satisfaction and relationship with family and friends,
professional insertion professional and financial situation,
recreational activities, intimate life
 Physical Medicine and Medical
Rehabilitation I

Types of therapy

Etiologic, pathophysiologic and symptomatic

pharmacologic treatment
Non-pharmacologic treatment
Physical factors:
Mechanic factors: therapeutic massage,
kinetotherapy agents (around the balance of
rest and movement), hydrokinetotherapy;
 Physical Medicine and Medical
Rehabilitation II
 Thermal factors - heat or low temperatures
(thermotherapy - application of heat, cryotherapy,
hydrotherapy);
 Electrical current (electrotherapy), phototherapy
(UV, LASER, IR); electromagnetic field;
 Natural Therapeutic Factors (balneotherapy):
climate, therapeutic mineral waters for internal
(crenotherapy) and external treatment, therapeutic
gases, mud (peloidotherapy), sand (psamotherapy);
 Others types of therapy: nursing, psychotherapy,
logopedy, occupational therapy, social workers
 Physical Medicine and Medical
Rehabilitation

The physical therapeutic unit recommended in

functional rehabilitation is represented by:
 thermotherapy: the heat or cold application
 Electrotherapy (electric current, electro-
magnetic field, radiant energy)
 kinesiotherapy (therapeutic physical
exercise)
 therapeutic massage
 Rehabilitation and Physical Medicine

CLINICAL AND FUNCTIONAL ASSESSMENT

IN MEDICAL REHABILITATION
 General Aim: Determining Disability
• Medical assessment and treatment of physical
dysfunction and associated disability defines the clinical
practice of recovery medicine.
• In 1980 WHO (World Health Organisation) has
developed ICIDH = International classification of
treatments, Disability and Disability – 4 levels:

1. Pathology = illness/trauma which causes changes in the

structure/function of a tissue/organ.(ex-arthrosis, AVC,
TVM, TCC, PR); included in ICD (International Classification
of Disease)
 Level of Disability

2. Impairment = dysfunction = appears at the organ level =

loss / abnormality of a structure or function resulting from
pathology (level 1) exhaustion, decrease F muscle

3.Disability = disability = appears at the person level =

restriction / lack of ability to perform an activity in a normal
manner (results from dysfunction-level 2) ex - cannot walk,
cannot perform ADL (activities of daily living)

4. Handicap = social level - participation = limits the normal

social and professional activity, depending on age, gender,
social / cultural factors.
 WHO- 1997 DEFINITIONS

• DISFUNCTION = loss / anomaly of a body structure or of a

physiological / psychological function

• ACTIVITY = nature and maximum degree of functioning at

the person level

• PARTICIPATION = nature and degree of interest of a person in

life situations, in relation to dysfunction, activity, health
conditions and contextual factors
 Evaluation in Rehabilitation Medicine
= Functional Evaluation
• The medical diagnosis focuses on the history
of the disease and the clinical examination -
identification of the disease
• The rehabilitation physician also evaluates
the functional consequences of the disease
and identifies disabilities
• The purpose of rehabilitation treatment is to
transform the disability of a person in a
positive aspect- physical, mental, social and
economic independence
 Team Work in Rehabilitation Medicine

• Rehabilitation Medical Doctor

• Physical therapist
• Occupational therapy assistant - evaluates the
performance during ADL
• Nurse
• Speech therapist - evaluates the function of the
language
• Psychologist-evaluates the cognitive and perceptual
function - the current psychological status
• Social assistant - the social and economic support
 CLINICAL AND FUNCTIONAL EVALUATION
• Anamnesis - outlines the patient's history
• Physiologic data
• Heredocolateral data
• Previous pathology and specific therapeutic history
• Personal, social and professional condition
• Behaviors
• General clinical presentation - the subjective and
pathological elements
• Functional aspects - for locomotor, respiratory,
cardio-vascular, nervous system
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION

• 1. HISTORY OF THE PRESENT DISEASE: location, onset,

symptom quality, context, severity, duration, modulating
factors, associated signs and symptoms

• 2. FUNCTIONAL HISTORY: mobility-within the bed,

transfers, in and with the wheelchair, walking, using the
car, necessary ADSL equipment (different types of self-
service: washing, dressing, eating, personal hygiene)
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION
• ADL instrumental activities
- food preparation, laundry, phone use, house cleaning,
pet care
- cognition
- communication
• 3. MEDICAL AND SURGICAL HISTORY
- specific conditions - cardio-pulmonary,
musculoskeletal, neurological, rheumatologic,
metabolic
- past and present medication
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION
• 4. SOCIAL HISTORY
- home environment and circumstances in which he
lives, benefit of support from the family and friends,
substance abuse, sexual history, vocational activities,
financial resources, recreational activities, psycho-social
history (mood disorders), religion
5. FAMILY HISTORY
6. GENERAL PHYSICAL EXAMINATION - cardiac,
pulmonary, abdominal, reno-urinary, methabolic
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION
• 7. NEUROLOGICAL EXAMINATION
• The level of consciousness
- Concentration, Orientation , Memory
- General knowledge, Abstract thinking, Judgment
- Disposition and affectivity, Communication
- Cranial nerves examination
- Superficial and deep sensitivity
- Motor-force control, coordination, apraxia,
involuntary movements, tonus
- Osteotendinous reflexes
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION
8. EXAMINATION OF THE MUSCULOSKELETAL SYSTEM
 Inspection – symmetry, joint deformations, atrophy
 Palpation
 Joint stability,
 Active and passive mobility (ROM),
 Muscle testing,
 Somatic pain: nociceptive and neuropathic pain
(joint, muscles, other soft tissue, neuropthy)
 ESSENTIAL ELEMENTS OF HISTORY AND
PHYSICAL EXAMINATION

MOBILITY ASSISTANCE DEVICES

1. CRUTCH – axillary, forearm, with platform
2. Walking Stick – unipodal, tri / tetrapodal, with
platform
3. FRAMES – standard, with rollers, with platform
4. WHEELS – manual, electric
5. ORTHOTICS – plastic, metallic
 IMPORTANT ISSUES IN
REHABILITATION MEDICINE

1. Aspects related to MOVEMENT CAPACITY

2. The ability to carry out different activities in daily
life-ADL
3. COMMUNICATION possibilities
4. SOCIAL INTEGRATION
5. PSYCHOLOGICAL INTEGRATION
 MOVEMENT CAPACITY
• MOBILITY = the ability to move in the environment,
plays a vital role in society, any dysfunction has
major consequences for the quality of the patient's
life
• the mobility in bed
– turning from one side to the other,
– from the supine position in pronation,
– lifting and sitting
 Prolonged rest induces deconditioning syndrome and
predisposes to pressure ulcers, deep vein thrombosis
and pneumonia
 MOVEMENT CAPACITY
• transfers - include transfer from bed, lift in
standing position from sitting in bed or from the
toilet chair,
• transfer from the wheelchair in the car or on the
couch / bathroom
• mobility with the wheelchair - if the propulsion is
independent, distance, if he needs help, the
degree of independence at home, in the
community, on the ramps
• walking - distance, if he/she need assistive devices
 MOVEMENT CAPACITY

• walking - it is important if symptoms appear

associated with walking (chest pain, dyspnea, pain,
dizziness), history of falling, instability when
walking, if they can go on rough terrain, if they can
climb stairs (how many?), if they need bars
• driving by car - important for transportation and the
level of independence - the elderly who can no
longer drive become depressed
 MOVEMENT CAPACITY
• Influencing factors
– cognitive, visual symptoms, slowed reaction time
– inferior members hypotonia, contractures,
coordination disorders, cognitive disorders due
to medication or organic diseases (dementia,
stroke, traumatic brain injury, depressive
disorders)
• alternatives must be found in order to use the
public or assisted transport
 ADL si I-ADL
• Assessment of chronic disease recovery often shows a loss of
function

• Through the functional history, the recovery physician

evaluates the disabilities resulting from the disease and
identifies the restant capacities

• ADL-activities of daily life-activities of personal care

- Bath and shower Going to the toilet
- Urination and defecation Dressing
- Eating Functional mobility
- Personal care Personal hygiene
- Sexual activity Sleep and rest
- The toilet hygiene
 I-ADL
• I-ADL represents the instrumental activities of daily life
- Caring for others Pet care - child care
- Use of communication devices Home cleaning
- Mobility in the community Financial resources
- Maintaining health Meals preparation
- Dish washing Shopping activities
- Procedures in case of emergency and emergency
response
- I-ADL = represents more complex activities necessary
to live independently in the immediate environment
but also to care for others
 COMMUNICATION
• Communication skills are used to convert
information
• thoughts
• needs
• emotions
• Verbal deficits (different states):
• may be subtle, changes observed by the family
• Some patients cannot communicate at all -
writing, signs, gestures, electronic devices
 COGNITION
• Represents the complex mental process of
knowledge
• Objective evaluation – memory, orientation, ability
to assimilate information
• Cognitive disorders can also be assessed
subjectively during anamnesis
• Some people with cognitive deficits do not
recognize the dysfunction, information must be
gathered from the family
• These deficiencies interfere with the recovery
program and pose patient safety problems
 COGNITION
• The level of cognitive – mental activity determine the
quality of all adapting processes involved in planning,
problem solving and self-recognition as part of an
independent life.
• Cognition is correlated with the functional prognosis.
• Example - patient with a history of stroke, falls, has a
hip fracture that requires prosthesis, has cognitive
disorders and cannot follow the necessary precautions
for prosthesis, may have a bad prognosis for
rehabilitation and risk of dislocation of the prosthesis.
 SOCIAL INTERACTION

• Adequate hospitalization possibilities

• Sufficient home care resources
• Psychological status
• Developing a depression
• Correcting it by improving functional aspects
 CONSEQUENCIES OF MEDICAL AND SURGICAL
HISTORY
• CARDIOPULMONARY PATHOLOGY
 Mobility, ADL and I-ADL, work or recreational
activities can be severely compromised
 History of ICC, chronic / acute IM, arrhythmias,
coronary heart disease, by-pass, transplant, stents
 NO PRESCRIPTION of physical exercises beyond the
effort limit
 Pulmonary disease – COPD (chronic obstructive
pulmonary disease) – functionally limited by
dyspnea
 Correction of Cardiovascular Risk Factors: smoking,
hypertension, obesity
 CONSEQUENCIES OF MEDICAL AND
SURGICAL HISTORY
• MUSCULOSKELETAL DISORDERS
 can be multiple, from acute traumatic injuries, to
gradual functional decline (OA)
 history of – trauma, arthritis, amputation, joint
contracture, musculoskeletal pain, congenital /
acquired disorder, weakness, instability
 It is important to understand the functional impact
of these dysfunctions or disabilities – for example –
shoulder pain secondary to the prolonged use of
the wheelchair
 CONSEQUENCIES OF MEDICAL AND
SURGICAL HISTORY
• NEUROLOGICAL DISEASES
 Compulsory to identify neurological conditions:
congenital / acquired, progressive / non-progressive,
central / peripheral, demyelinating / axonal, sensitive /
motor
 Establish and understand the pathophysiology,
topography, severity, prognosis, implications of the
rehabilitation program
 Indication for assistive devices, orthotics
 Identification of speech and swallowing dysfunction, pre-
existing cognitive impairment
 CONSEQUENCIES OF MEDICAL AND
SURGICAL HISTORY
• RHEUMATOLOGIC DISEASES
- the personal history must identify and asses the type of
rheumatologic disease (the no. of acute episodes,
topography and the number of joints affected, pain,
orthopedic procedures performed)
PREVIOUS MEDICATION
 Allergy to medication / food
 Drugs used
 Attention to the abuse of NSAIDs
 Indications, precautions, effects explained to the
patient
 History of the Disease in
Rehabilitation
• Reasons for rehabilitation program
• The dynamics between the clinical aspects and the
loss of function (hemiplegic - the possibility of
movement, care, communication)
• Chronological sequences - clinical evolution and
functional changes
• Living conditions, diet, alcohol, coffee
• The social-professional context
• Background of associated pathology
 OBJECTIVE CLINICAL EXAMINATION
ASSESMENT OF CARDIO-VASCULAR AND
RESPIRATORY SYSTEM
 The presence of precordial pain, dyspnea, heart rhythm
disorders, claudication on inferior limb restrict the request
for physical training
 Obstructive / restrictive respiratory dysfunction
 The level of the physical program request will be
established after assessing the cardio-pulmonary reserve
 Blood Pressure dynamics
 Heart size, rhythm, heart sounds
 Peripheral and carotid pulse
 Skin temperature
 Peripheral edema
 Cyanosis presence, pulmonary stethacoustic noises changes
 OBJECTIVE CLINICAL EXAMINATION

• NERVOUS SYSTEM-PERIFERAL / CENTRAL EXAMINATION

• MUSCULOSKELETAL EXAMINATION
• pain, hypotrophy, inflammation, edema, limiting joint
mobility (ROM)
• GENITO-URINARY AND RECTAL EXAMINATION
• Changes in urinary / intestinal sphincter control - urinary
incontinence due to perineal rupture or stroke, TCC, TVM,
tonal changes of anal sphincter, fecal incontinence in TVM
and TCC
• Urinary infections – E. Coli, Proteus, Pseudomonas.
RELATIONSHIP WITH THE ENVIRONMENT

• Communication defects interfere with the

recovery program (stroke patients or head
trauma).
• Abilities of visual, auditory and other sensory
levels compensate some communication deficits.
• Visual field loss, hearing loss, proprioception
deficiency and other sensory deficiencies have a
negative influence in the patient's behavior and
the evolution of the recovery program.